PLEASE PRINT CLEARLY THE UNIVERSITY OF TEXAS AT TYLER 1. myUTTylerID # ______ PROBATIONARY CERTIFICATION 2. Social Security #______

4. Today’s Date______Probationary Certification for Professional Certificates 3. TEA # ______

5.Last Name First Name MI Maiden Name
6. Permanent Address City State Zip Code
7. Date of Birth
(numerical MM/DD/YYYY)
/ / / 8. Gender
 Male
 Female / 9. Ethnicity (choose ONE)
Hispanic/Latino
Not Hispanic/Latino / 10. Race (choose one or more)
American Indian or Alaska Native Asian
Black or African American
Native Hawaiian or Other Pacific Islander White
11. Telephone
( ) / 12. E-mail address
13. HighestDegree Earned to date / 14. Date of that degree (MM / DD / YYYY)
/ / / 15. University
16. Program governing certification plan:
Educational Diagnostician Reading Specialist
Superintendent School Counselor
Principal
Master Reading Teacher
NOTICE: Applicants for Professional Certification must provide a service record from the school district showing at least 2 years of teaching experience. 3 years are required for the MRT. / 17. Target Certification:
____ Professional ______

18. FOR ADDITIONAL CERTIFICATION:POSITION HELD WHILE ON PROBATIONARY CERTIFICATE:

______

Position Grade(s) Subject (if applicable) Campus

______

ISD

**NOTICE: Any information left blank will delay the recommendation process. ALL INFORMATION IS REQUIRED.**

Do not write below this line

TExESNotes: Svc Record in ImageNow

# Yrs. Classroom Teaching______

______

______

Checked/degree

______

______

______

______

Recommended Certifications:

______

______

Date of Recommendation______

**DISCLOSURE STATEMENT:

Disclosure of your Social Security Number (“SSN”) is required of you in order for The University of Texas at Tyler to provide the number to the State Board for Educator certification (SBEC) as mandated by SBEC internal rules. Your SSN will be used by SBEC in order to conduct criminal history checks required for applicant certification. Further disclosure of your SSN is governed by the Public Information Act (Chapter 552 of the Texas Government Code) and other applicable law.

PRIVACY STATEMENT:

With few exceptions, you are entitled on your request to be informed about the information The University of Texas at Tyler collects about you. Under Sections 552.021 and 552.023 of the Texas Government Code, you are entitled to receive and review the information. Under Section 559.004 of the Texas Government Code, you are entitled to have The University of Texas at Tylercorrect information about you that is held by us and that is incorrect, in accordance with the procedures set forth in The University of Texas System business Procedures Memorandum 32. The information that The University of Texas at Tyler collects will be retained and maintained as required by Texas records retention laws (Section 441.180 et seq. of the Texas Government Code) and rules. Different types of information are kept for different periods of time.

07/05/2017